Jack Hutter DPM, C.ped, FACFAS, FAPWCA, Diplomate, ABPFAS

Laser therapies

Chemical treatment of verruca plantaris

Minimally invasive surgical of heel pain caused by plantar fascitis

Treatment of plantar fibromatosis

Laser antimicrobial therapy

Multiwave Locked System laser

UV- C 100 – 280 nm

UV- B 280 – 315 nm

UV- A 315 – 400 nm

VIS 400 – 560 nm

IR – A 560 – 1400 nm

IR- B 1400 – 3000 nm

IR- C 3000 – 10,600 nm

Light Amplification by Stimulated Emission of Radiation

IR – A 870 and 930 nm non thermal photoinactivation ( Noveon)

IR – A 532 – 595 nm thermal ablation leading to disintegration and vaporization ( CuteraGenesis Plus)

UV – C 254 nm pigment specific photoablation, mutagenic interaction on genetic material

Specific intracellular chromophores in tissue absorb radiation, providing varying degrees of filtration of emissions

Therapeutic window refers to wavelengths from 600 to 1200 nm

Less chromophores in this range allows for greatest tissue penetration of emission

Thermal injury to treated and adjacent tissues

Mutagenic effects through genetic material alteration

Ocular damage

Respiratory effects ( vapor plume from 1 gm of ablated tissue equals roughly 5 cigarettes )

UV - C VIS

100 – 280 nm ( 254 nm )

antibacterial and antifungal through genetic alteration

wound decolonization (includes MRSA ), treatment of onychomycosis

Keraderm

400 – 560 nm (532 nm)

pulsed Nd:YAG laser

pigment specific tissue ablation

Antifungal,verrucaplantaris ablation

Pinpointe, Patholase, Cutera Genesis Plus

ND:YAG PHOTO/THERMALABLATION

400 PULSES 12 -16 J/CM2, 3 HZ, 5MM SPOT SIZE, DURATION 3 MS

IR - A

560 – 1400 nm ( dual wavelength 870 nm and 930 nm laser

specific non-thermal photo inactivation of fungal and bacterial pathogens, not harmful to normal cells

wound antisepsis including MRSA

Potentiating antibiotic efficacy (Ciprofloxacin, erythromycin, tetracycline )

Two separate wavelengths emitted simultaneously

One emission is continuous, providing anti-inflammatory and anti-edemic effects

The other emission is pulsed and provides analgesic effects

Effective in tendonitis, sprains, DJD and arthridities, effusions, bursitis, contusions, venous ulcerations, burns, fascitis, trauma, wound healing

5% fluorouracil cream ( 5 FU, Efudex )

Interferes with the synthesis of DNA and RNA

Effect most marked on those cells that grow more rapidly and take up fluorouracil at a more rapid rate

Treatment may take at least two months

Contraindicated during pregnancy and if breast feeding

Especially applicable in cases of large or many lesions

Not to be used on inflamed or open skin

Avoid contact with eyes and mucous membranes

Occlusion increases absorption

Integument includes ulceration, pruritis, contact dermatitis, scarring, UV light photosensitivity

Infrequently GI, CNS, hematologic events

Scalpel debridement every three weeks

Patient applies 5 FU cream under tape occlusion to verruca daily, morning and evening

Every other evening patient applies mediplast40% salicylic acid patch over verruca, instead of 5 FU, to be left on overnight

Removal of mediplast the next morning provides a chemical debridement effect

Caution patient to discontinue treatment if any blistering, ulceration or break in skin develops

Topical Treatment Options

Topaz Minimally Invasive Microdebridement

Plantar fascia bands originate at plantar tubercles, extending proximally to blend with the achilles tendon, distally to blend with the flexor tendons under the MTPJ’s and distally to the toes

The greatest amount of linear stretch through the plantar fascia is medial plantar, with fascitis most frequently presenting as inflammation of the medial fascia band attachment to the calcaneus

Acute trauma causing an excessive stretch through the plantar fascia ( sudden dorsiflexion of the toes or hyperextension of the foot on the ankle )

Chronic sub- acute trauma to the fascia attachment at the calcaneus, often related to biomechanical abnormality and resulting in calcaneal hypertrophy within the plantar fascia

Longitudinal arch structure

Ankle, forefoot equinus

Body weight

Barefoot ambulation

Joint inflammatory disease Poor or inappropriate shoe gear

Ambulatory surface (hard vs. soft, incline, ladder, steps )

Often can contribute to development of heel pain

Incline contributes to excessive pronation and abduction and greater plantar fascia stretching

Increased speed adds to mechanical stresses on the plantar fascia

Running on the treadmill creates greater heel strike and accentuated pronation

Especially problematic if the patient has significant equinus

Pain on the bottom of the heel, sometimes referred to arch

Mininal pain off weight bearing

More constant pain in chronic cases

Painful when driving

Often no history of trauma, gradual onset

Worse when ambulating barefoot

Pain on palpation at the origin of the plantar fascia from the calcaneus

Minimal pain at the body of the calcaneus,

Negative Tinel sign

No erythema or local temperature increase

No overlying skin or subcutaneous lesions

X-ray may show heel spur

MRI if suspect fascia tear

SHORT TERM TREATMENT (RESOLUTION PHASE )

LONG TERM TREATMENT (MAINTENANCE PHASE )

Medications

Support

Plantar fascia and achilles tendon stretching at least b.i.d

Limit ambulating barefoot

Continue stretching routine

Avoid barefoot ambulation

May need to alter activities to avoid reoccurrence

Cornerstone in treatment is orthotic control

Medications – Oral or topical NSAID, oral or injected steroid

Support – taping, in shoe padding, Powerstep, BFO

Stretching and massage – passive, plantar fascia and achilles tendon, anterior or posterior night splint, b.i.d, tennis ball, frozen juice can

Limit walking barefoot – croc, birkies, ortha heel

Rest – alter walking activities i.e.. Reduce mileage, speed and frequency of workout, change to non-loading force workout ( bike, elliptical )

Passive stretching morning and evening and before and after workout

Get in the habit of limiting barefoot ambulation

Alter workout routine

Appropriate shoe gear and orthotics

Shoe design

Topical options

Minimally invasive microdebridement

Multiwave Locked System laser

Well known technology to podiatry and pedorthics

Traditionally found in many running shoes and orthopedic shoes

Seems to be a new trend in walking shoes

First developed by MBX

Newer siblings Easy Spirit, Sketcher ,New Balance, Avon, Curves, Apex

MBX Rocker Shoe - Arguably the prototype of the current influx of similar style shoes

POSITIVES NEGATIVES

More efficient gait

Unloading of heel and forefoot

Increased shock absorption

More heel and toe spring, could be too drastic for patients with balance problems

Negative heel effect from heel spring can be intolerable for patients with significant ankle equinus

Rigid orthotics can be uncomfortable due to increased pressure at arch

VOLTAREN GEL FLECTOR PATCH

Topical version of oral NSAID Voltaren ( diclofenac sodium )

Indicated for tendonitis, also being used for plantar fascitis

16 gm total per day ( 2-4 gm bid or tid )

Minimal systemic absorption, but should not be used concurrent with oral NSAID

Diclofenac sodium embedded in an adhesive patch for topical absorption

Similar indications as Voltaren gel

Apply q12h Awkward in plantar

fascitis as is difficult to maintain in position during ambulation

Minimal systemic effect

Topaz microdebridement Indicated for treatment of chronic plantar fascitis (

6 - 8 months of failed conservative care ) Thermographic studies show that the plantar

fascia in the chronic state of fascitis is hypovascular, making it unresponsive to treatment

Acute state of fascitis is hypervascular Microdebridement allows for plantar fascia

revascularization Increased local vascular perfusion allows for

plantar fascia repair, 1 – 3 months of recovery, minimal complications

Bipolar plasma mediated radiofrequency coablation

68,000 cases

Minimal tissue damage, few reported complications

Indicated for debridement of soft tissue within the shoulder, elbow, knee, foot, ankle

Single application

Outpatient or office procedure, local anesthesia

Two different techniques, open and percutaneous

Partial tear of the plantar fascia

Acute trauma

Neurogenic disease

History of keloids

In extremely severe cases the chronic inflammation of the plantar fascia may be too extensive for success, requiring an open fasciotomy

Patient must be off any anti-inflammatory one week prior to surgery and two weeks after

PERCUTANEOUS OPEN

Palpate to locate area of maximum symptoms

Administer local anesthesia

Sterile prep

Using sterile technique mark a grid pattern of penetration points directly over the symptomatic area on the plantar surface with a sterile marker

One at a time at each grid point percutaneously produce a guide hole using a.062 in. K-wire down to the plantar fascia followed by the Topaz wand

Penetration depths should vary between 1,3,and 5 mm, 12 – 16 holes

Location of symptoms, anesthesia and prep same as percutaneous

Linear skin incision

Dissect to plantar fascia

Produce grid pattern with the Topaz wand into the plantar fascia

Same penetration depths and number of holes,

Flush and standard closure

GRID PATTERN FOR PERCUTANEOUSMICRODEBRIDEMENT

GRID PATTERN FOR OPEN MICRODEBRIDEMENT

0.62 K-WIRE GUIDE HOLES THROUGH THE PLANTAR FASCIA

FOLLOW GUIDE HOLES WITH TOPAZ MICRODEBRIDEMENTWAND

First three weeks crutch ambulation, immobilize with splint or cast

Week 4 – 8, passive and active range of motion exercises and Night splint-Cam walker as appropriate

2 -3 months, no sports or heavy lifting, routine at home or work is okay at surgeon discretion

Post op recommendations taken from Topaz literature

Plantar fibromatosis is a fibrotic tissue disorder of the plantar aponeurosis characterized by excess collagen formation and fibrosis

Fibromatosis may be palpable as single or multiple firm nodules, or can be nonpalpable with generalized fascia thickening

Sometimes bilateral MRI confirms diagnosis and rules out sarcoma Traditional treatment includes unloading,

injections or surgery A new option in treatment is Transdermal

Verapamil Gel

Ten times more often in males

Caucasians of northern European descent tend to be more affected

25% in middle age to elderly

Increased incidence in diabetes mellitus and seizure disorders

Trauma to the plantar aponeurosis causing overproduction of collagen/fibrotic tissue

Reduction in normal tissue elasticity and local prominence contributes to pain on ambulation

Genetic predisposition to fibromatosis and other fibrotic tissue disorders

May have concurrent Dupuytren’s contracture

Beta blocking agents, antiseizure medications, glucosamine/chondroitin, large doses of vitamin C can promote the production of excess collagen

Local steroid injections usually fail as the density of the fibromatosis does not allow adequate medication dispersion

Multiple injections may worsen the condition due to trauma

Nonpalpable fibrosis is indiscernible, thereby making injection therapy ineffective

Surgical removal has a 57% rate of reoccurrence, but may need consideration in cases of larger lesion

Orthotics are used to manage pain symptoms but will not resolve the problem

Transdermal Verapamil Gel offers resolution with less risk of complications

Verapamil is a calcium channel blocker

The flow of calcium into fibroblasts through calcium channels in the cell membrane is required for the production of excess collagen that forms the plantar fibroma

By blocking the calcium channels Verapamil slows or stops collagen production in fibroma growth

Calcium channel blockage also causes increased fibroblast collagenase production which allows for fibroma collagen reduction

Apply to the entire plantar aponeurosis, treating both palpable and non-palpable fibromatosis

Fibrosis reduction works cumulatively, adequate concentration levels need to be built up and maintained for sustained collagenaseactivity

No systemic or localized adverse effects have been reported

Standard treatment time is 6 – 12 months

Beta blockers used to treat hypertension and cardiac arrythmia can cause tissue fibrosis, may reduce effectiveness of Verapamil

Oral Verapamil can interfere with the metabolism and elimination of statin drugs, digoxin/cyclosporin, with risk of toxic levels –Transdermal Verapamil has minimal systemic absorption, but patient should be advised about this possible adverse effect

Nicotene impedes the skin’s ability to absorb topical medications

Do not apply under occlusion

Wash and dry bottom of affected foot

Apply two 0.5 ml doses twice per day using the dosimeter included with the medication

Each application is to the entire bottom of the foot

Massage the medication into the skin for approximately 1 – 2 minutes, wait 5 minutes, then continue to rub into the skin for another 1 – 2 minutes

Repeat the application process

The application procedures should be repeated morning and evening every day

In Severe Cases of Plantar Fibromatosis, Surgical Intervention

May Be Necessary………..

Surgery in Plantar Fibromatosis

Dissecting the Lesion

Distal fascia band

Onychomycosis Keraderm, Pinpointe , Patholase, and Noveon laser systems

Wound care/antisepsis Patholase, Pinpointe, and Noveon laser systems

Antibiotic potentiation Noveon laser systems Plantar fascitis MLS laser systems, Topaz

Arthrocare Sports Medicine, MBX shoes,Voltarengel, Flector Patch King Pharmaceuticals

Plantar fibromatosis Pd labs transdermalverapamil

Verruca plantaris Efudex ICN Pharmaceuticals, Pinpointe, Patholase